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Zentralbl Chir 2014; 139(1): 58-65
DOI: 10.1055/s-0032-1328351
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Die Rolle der peroralen endoskopischen Myotomie (POEM) bei der ösophagealen Achalasie

The Role of Peroral Endoscopic Myotomy (POEM) in Achalasia
J. P. Charton
Medizinische Klinik, EVK, Düsseldorf, Deutschland
,
B. Schumacher
Medizinische Klinik, EVK, Düsseldorf, Deutschland
,
T. Toermer
Medizinische Klinik, EVK, Düsseldorf, Deutschland
,
H. Neuhaus
Medizinische Klinik, EVK, Düsseldorf, Deutschland
› Author Affiliations
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Publication History

Publication Date:
05 August 2013 (online)

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Zusammenfassung

Die Achalasie ist eine seltene Motilitätsstörung des Ösophagus. Charakteristisch für die klassische Achalasie sind eine fehlende propulsive Peristaltik des distalen Ösophagus sowie eine inkomplette Relaxation des unteren Ösophagussphinkters. Etablierte Verfahren zur Therapie der Achalasie sind die endoskopische Ballondilatation des unteren Ösophagussphinkters oder die laparoskopische Myotomie nach Heller. Beide Therapieverfahren gelten als vergleichbar effektiv. Kürzlich wurde mit der peroralen endoskopischen Myotomie eine neue definitive Therapieoption eingeführt. Dieses minimalinvasive Verfahren wurde bisher erst in wenigen klinischen Studien evaluiert. In der folgenden Übersicht wird die perorale endoskopische Myotomie vorgestellt und ihr Stellenwert in Abgrenzung zum chirurgischen Vorgehen herausgearbeitet. Zur Diagnosestellung der Achalasie ist eine klinische Anamnese und Symptomanalyse, eine Ösophagusmanometrie sowie eine Röntgendarstellung des Ösophagus sinnvoll. Endoskopisch sollte zudem eine andere Ursache der Dysphagie ausgeschlossen werden. Die Beschwerden sollten möglichst anhand eines Symptom-Scores erfasst werden. Bei der POEM wird endoskopisch zunächst im mittleren Ösophagus eine Mukosainzision durchgeführt. Anschließend erfolgt in Längsrichtung eine Tunnelung der Submukosa bis etwa 2 cm distal des gastroösophagealen Übergangs mit nachfolgender Myotomie (zumindest) der zirkulär verlaufenden Muskelschicht des distalen Ösophagus und der angrenzenden Kardia. Abschließend wird die Mukosainzision wieder mit Metallclips verschlossen. Die ersten Ergebnisse dieser Methode sind sehr vielversprechend und zeigen eine signifikante Besserung der Symptomatik und Reduktion des Ruhedrucks des unteren Ösophagussphinkters. POEM ist eine neue, minimalinvasive Therapieoption der ösophagealen Achalasie. Die ersten Ergebnisse sind sehr vielversprechend; Langzeitergebnisse sowie Vergleichsstudien mit etablierten Therapieverfahren müssen jedoch noch abgewartet werden.

Abstract

Achalasia is a rare motility disorder of the oesophagus. Classic achalasia is characterised by a lack of propulsive peristalsis of the distal oesophagus and incomplete relaxation of the lower oesophageal sphincter (LES). Traditionally achalasia is treated either endoscopically by pneumatic balloon dilatation or laparoscopically by Hellerʼs myotomy. Both therapeutic procedures show a comparable effectiveness. Recently, peroral endoscopic myotomy was introduced as a new definitive treatment option. So far, this minimally invasive therapy was evaluated in a few clinical studies only. In this survey, peroral endoscopic myotomy is presented and compared to the well established surgical treatment. The diagnosis of achalasia is based on the patientʼs medical history and analysis of symptoms and particularly on oesophageal manometry. In addition, a barium swallow (oesophagram) and upper endoscopy are performed to rule out other reasons causing dysphagia. The patientʼs complaints should be recorded by use of a symptoms score. The POEM procedure starts with an incision of the mucosa at the level of the mid-oesophagus. Then, a submucosal tunnel is created distally passing approximately 2 cm over the oesophagogastric junction. After this step, myotomy of (at least) the circular muscle bundle of the distal oesophagus is performed and should be extended to a distance of 2 cm over the cardiac. Finally the mucosal entry site at the level of the mid-oesophagus is closed with endoscopic clips. First results of this technique are very promising with significant symptom relief and reduction of the mean LES pressure. In conclusion, POEM is a new, minimally invasive therapeutic option for the treatment of oesophageal achalasia. First results are very promising; long-term results and results of comparative clinical trials with established treatment methods must be awaited.

Schlüsselwörter

Achalasie - Myotomie - endoskopische Intervention - POEM - Hybridknife - Endoskopie

Key words

achalasia - myotomy - endoscopic intervention - POEM - hybrid knife - endoscopy
 

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